Pediatric Moyamoya Disease in Nepal and Challenges in a Resource-Limited Setting: A Case Report.

Moyamoya disease (MMD) is a rare progressive cerebrovascular disorder characterized by stenosis of the terminal internal carotid arteries with fragile collateral vessel formation. It is common in East Asia but underreported in Nepal. Pediatric cases typically present with ischemic symptoms such as transient ischemic attacks, stroke, or seizures. We report a 7-year-old Nepali boy with 11 days of fever followed by recurrent tonic-clonic seizures, progressive right-sided weakness, and impaired fine motor function. Examination showed right hemiparesis with an upgoing plantar reflex. MRI and MR angiography revealed multiple acute infarcts with supraclinoid internal carotid artery stenosis and extensive collateral vessels, confirming MMD. Cerebrospinal fluid and autoimmune workup were unremarkable. The child was managed conservatively with aspirin and levetiracetam, leading to partial recovery. Surgery was deferred due to financial limitations and initial improvement. This case underscores the importance of considering MMD in pediatric strokes in non-endemic regions. In resource-limited settings like Nepal, conservative treatment offers symptomatic relief, but long-term follow-up is essential to monitor progression and surgical needs.